Efficacy of buccal pad fat as a new approach in the treatment of gingival recession: a systematic review

OBJECTIVE

This systematic review evaluates the efficacy of buccal pad fat (BPF) as an autologous graft in the treatment of gingival recession (GR). Thus, the research question explores if the BPF can serve as a viable alternative to the gold standard connective tissue graft.

MATERIALS AND METHODS

Only seven studies met the inclusion criteria were critically appraised including the randomized controlled clinical trials, and case series. The inclusion criteria were systemically healthy individuals in the age range (18-65 years old) with Miller's classification of GR either class I, II, III, or IV while exclusion criteria were patients with poor oral hygiene, pregnant and lactating patients, teeth with caries, any prior surgery in the relevant regions, and use of medications.

RESULTS

The review included 117 patients with 136 GR defects. The age of participants ranges from 20 to 65 years old with the higher percentage of root coverage (%RC) at 6 months in the pedicled BPF group which was 89.30%while the lowest (%RC) at 6 months in the same group was 46.78%. The BPF group's width of keratinized gingiva (WKG) values indicate a notable improvement, suggesting a positive impact on WKG compared to the control group.

CONCLUSIONS

BPF can be considered as a promising graft to augment gingival tissues at different sites in the oral cavity with different Miller's classes of GR providing a new era in GR treatment.

Effect of a powered and a manual toothbrush in subjects susceptible to gingival recession: A 36-month randomized controlled clinical study

OBJECTIVE

The objective of this long-term clinical study was to evaluate the influence of a newly developed powered toothbrush (PT) on the size and number of pre-existing gingival recessions (GR) in comparison to a manual toothbrush (MT).

METHODS

This was a prospective, single-blind, parallel-group, randomized controlled clinical study. Participants without periodontitis, but with at least two teeth (index teeth) showing GR ≥2 mm were randomized to brush either twice daily with a MT or with a PT with a linear magnetic drive causing the round brush head to produce gentle micro vibrations along with oscillating-rotating movements. Primary outcome parameter was the mean change of GR at the index teeth over 36 months.

RESULTS

Totally 87 out of 92 participants completed the study (MT/PT: n = 42/n = 45). At the 36-month evaluation the mean (standard deviation) change of GR at index teeth differed significantly between MT 0.17 (0.77) and PT -0.10 (0.63) (p = 0.013). Furthermore, the amount of GR sites which improved ≥1 mm or remained stable during the study period did not differ between MT and PT, but the number of sites worsened ≥1 mm was significantly in favour for PT (MT 23 (25.5%) versus PT 10 (10.6%); p = 0.009). A binary logistic regression identified tooth type (OR = 2.991 for pre-/molar (1.096 [95% CI 1.002-8.933]; p = 0.050)) and manual brushing (OR = 3.341 (1.206 [95% CI 1291-8648]; p = 0.013)) as risk factors for recession impairment at the index teeth. There were no differences between groups for adverse events.

CONCLUSION

In a population with pre-existing gingival recessions and consequently a high risk of developing further recession the PT seems to be favourable with regard to further development of GR.

Epithelial cyst following subepithelial connective tissue graft: A case report

BACKGROUND

Various surgical approaches have been employed to manage gingival recession, including subepithelial connective tissue grafting, which has yielded favorable outcomes.

METHODS AND RESULTS

We present the case of a 17-year-old patient who developed gingival recession on tooth #6 following an esthetic crown lengthening procedure. The recession was treated with a subepithelial connective tissue graft; however, this case details the occurrence of two epithelial cysts adjacent to the region subjected to the surgical procedure, 6 months after surgery. The treatment involved periodontal surgical intervention, during which the lesions were completely excised and the associated osseous defect was filled using an inorganic bovine bone matrix along with a collagen membrane. The healing progressed without any complications. Histopathological analysis revealed the presence of cystic lesions, which were characterized by a cystic cavity lined with stratified orthokeratinized epithelium with cuboidal cells in some areas surrounded by fibrous connective tissue. The patient's progress was monitored through tomography performed 6 months, 1 year, and 5 years post-procedure, all of which demonstrated the absence of any signs of lesion recurrence.

CONCLUSION

This case study emphasizes the effectiveness and predictability of subepithelial connective tissue grafting in the treatment of gingival recession. However, dental professionals should be cautious about the potential risk of gingival recession following esthetic crown lengthening procedures and recognize the potential complications associated with subepithelial connective tissue grafting, such as the observed development of epithelial cysts in this specific case.

KEY POINTS

Why is this case new information? We present a case of an epithelial cyst following a subepithelial connective tissue graft, which resulted in buccal cortical bone resorption. The treatment involved excisional biopsy and the use of an inorganic bovine bone matrix with a collagen membrane. What are the keys to the successful management of this case? Successful treatment included periodontal surgery, bone defect filling using an inorganic bovine bone matrix and a collagen membrane, and regular monitoring with CT scans at 6 months, 1 year, and 5 years post-surgery; all showed no recurrence. Success factors included careful surgery, appropriate biomaterial usage, and ongoing follow-up. What are the primary limitations to success in this case? The limitations involve potential complications from subepithelial connective tissue grafting such as cyst development. This report stresses the importance of meticulous patient selection and periodontal phenotype evaluation to minimize risks. Continuous follow-up is critical to detect recurrence and other issues.

A Review of Gingival Recession and the Surgical Managements According to Their Classification and Etiologic Backgrounds: A Clinical Case Study

Mucogingival deformities are a group of defects that occur around the cervical area of the teeth. Gingival recession is the most common type of these deformities. It might happen separately or with other related deformities like thin gingival biotypes, shallow vestibule, high frenal attachment, and cervical dental steps. Recent classification of mucogingival deformity matrix has collectively grouped gingival recession types with other mucogingival deformities and dental steps to establish the proper diagnosis and evaluate surgical/restorative management and prognosis of the treatment outcomes. The following case presentations have presented with a technical review, clinical evaluation, and surgical and/or restorative treatment according to the recent matrix.

Assessing the Reliability of Miller's Classification and Cairo's Classification in Classifying Gingival Recession Defects: A Comparison Study

Background and Objectives: Gingival recession results in adverse aesthetics and root sensitivity, and there is a need to treat and prevent its further progression. To overcome these problems, various advances have been made by clinicians in treating gingival recession based on the type of gingival recession. Miller's classification has been used for a long time to classify the type of recession. However, certain limitations have been found with use of Miller's classification such as a lack of clarity in the method for measuring soft and hard tissue loss in the interproximal area. Cairo classification was proposed to overcome limitations of Miller's classification to classify gingival recession. Cairo's classification is a treatment-oriented classification based on buccal and interproximal attachment loss. Therefore, the study was conducted to assess and compare the reliability of Miller's and Cairo's classifications in determining gingival recession. Material and methods: A total of 220 buccal gingival recession defects were included in the study based on the inclusion and exclusion criteria. Four examiners were included in the study. Two examiners classified the recession defects according to Miller's classification and the other two examiners classified recession defects according to Cairo's classification at baseline and at a 1-week interval. Statistical analysis was conducted using SPSS software version 25.0 using Cohen's kappa correlation coefficient and Chi-square test statistics to determine the intra- and inter-rater agreement among the examiners for the two gingival recession classification systems. A p value of <0.05 was considered statistically significant. Results: The intra-rater agreement for Cairo's classification was 0.86 and 0.82, whereas for Miller's classification, it was found to be 0.68. The inter-rater reliability agreement for Cairo's classification was 0.82 and 0.8, whereas for the Miller's classification, it was 0.56 and 0.67. Conclusions: Within the limitations of the study, it was found that Cairo's classification is clearer and more reliable than Miller's classification in the assessment of gingival recession.

Electrospun methacrylated natural/synthetic composite membranes for gingival tissue engineering

New functional materials for engineering gingival tissue are still in the early stages of development. Materials for such applications must maintain volume and have advantageous mechanical and biological characteristics for tissue regeneration, to be an alternative to autografts, which are the current benchmark of care. In this work, methacrylated gelatin (GelMa) was photocrosslinked with synthetic immunomodulatory methacrylated divinyl urethanes and defined monomers to generate composite scaffolds. Using a factorial design, with the synthetic monomers of a degradable polar/hydrophobic/ionic polyurethane (D-PHI) and GelMa, composite materials were electrospun with polycarbonate urethane (PCNU) and light-cured in-flight. The materials had significantly different relative hydrophilicities, with unique biodegradation profiles associated with specific formulations, thereby providing good guidance to achieving desired mechanical characteristics and scaffold resorption for gingival tissue regeneration. In accelerated esterase/collagenase degradation models, the new materials exhibited an initial rapid weight loss followed by a more gradual rate of degradation. The degradation profile allowed for the early infiltration of human adipose-derived stromal/stem cells, while still enabling the graft's structural integrity to be maintained. In conclusion, the materials provide a promising candidate platform for the regeneration of oral soft tissues, addressing the requirement of viable tissue infiltration while maintaining volume and mechanical integrity. STATEMENT OF SIGNIFICANCE: There is a need for the development of more functional and efficacious materials for the treatment of gingival recession. To address significant limitations in current material formulations, we sought to investigate the development of methacrylated gelatin (GelMa) and oligo-urethane/methacrylate monomer composite materials. A factorial design was used to electrospin four new formulations containing four to five monomers. Synthetic immunomodulatory monomers were crosslinked with GelMa and electrospun with a polycarbonate urethane resulting in unique mechanical properties, and resorption rates which align with the original design criteria for gingival tissue engineering. The materials may have applications in tissue engineering and can be readily manufactured. The findings of this work may help better direct the efforts of tissue engineering and material manufacturing.

Evaluation of platelet derived growth factor-BB levels in injectable platelet rich fibrin coated graft using gingival pedicle split thickness tunnel technique for isolated gingival recession: A randomized controlled trial

Background

Use of injectable-platelet rich fibrin (i-PRF) in the field of periodontal regeneration is quite well known due to its efficacy. The study was aimed to evaluate the platelet derived growth factor-BB (PDGF-BB) levels in cases of isolated gingival recession using gingival pedicle split thickness tunnel technique (GPST) and de-epithelialized gingival graft (DGG) with or without coating it with i-PRF.

Methodology

20 patients exhibiting Miller's class I/II isolated gingival recession were selected for this parallel arm randomized controlled trial. Recipient site was prepared using GPST technique, free gingival graft was harvested and de-epithelialized, further graft was coated with i-PRF and wound fluid samples from surgical site were collected at baseline, 3rd day and 7th day for group A. The same procedure without coating the graft in i-PRF was carried out for group B. Clinical parameters like probing depth, recession depth, recession width, width of keratinized gingiva, wound healing index (WHI), complete root coverage was recorded at baseline and after 4 months.

Results

Significant intergroup difference was seen in WHI and the levels of PDGF-BB from baseline to the last estimated time point (p < 0.05).

Conclusion

The study emphasizes on the use of novel GPST technique in conjunction with DGG coated with liquid PRF, which has shown sustained release of PDGF-BB resulting in better wound healing.

A comparative study of cyanoacrylate-based tissue adhesive and surgical sutures on marginal flap stability following coronally advanced flap

INTRODUCTION

The present study evaluated the biomechanical characteristics of cyanoacrylate-based tissue adhesive (TA) compared to surgical sutures in coronally advanced flap (CAF) procedures using an ex-vivo model.

MATERIAL AND METHODS

Thirty-six half-pig mandibles were divided into three groups, n=12 each: (I) CAF fixed with sutures (sling and tag suture technique), (II) CAF fixed with TA, and (III) CAF fixed with sutures and TA. At mandibular premolars, gingival recession defects extending 3 mm apical to the cemento-enamel junction (CEJ) were created. CAF procedures were performed using a split-full-split approach, with coronal advancement of the flap to 1 mm above the marked CEJ and stabilization according to the respective groups I-III. Marginal flap stability against pull-of forces (maximum tensile force) was measured with a universal material testing machine until the CEJ became visible.

RESULTS

The comparison between groups I-III demonstrated a significantly increased maximum tensile force for the TA (II) compared to the suture group (I) (p<0.001). A significantly increased maximum tensile force was found for the suture and TA (III) compared to the suture group (I) (p<0.001). There was also a significantly increased maximum tensile force in the suture and TA (III) compared to the TA group (II) (p<0.001).

CONCLUSION

The results suggest that cyanoacrylate-based TA can increase marginal flap stability compared to sutures in CAF procedures.

CLINICAL RELEVANCE

Cyanoacrylate-based TA can be considered a useful and valuable adjunct to conventional suturing techniques in periodontal plastic surgery, especially in cases where high flap stability is required. The results of this ex-vivo study can only be transferred to the clinical situation with limitations. Clinical long-term follow-up data must be generated.

The prevalence and common risk indicators of root caries and oral health service utilization pattern among adults, a cross-sectional study

Background

Root caries is a prevalent oral health concern among adults, yet there remains a need for a comprehensive understanding of its occurrence and associated risk indicators. The present study was aimed to investigate the prevalence of root caries and to determine significantly associated indicators with it among adults.

Methods

The residents aged 35-74 years old were enrolled in a cross-sectional study in which dental examination were taken and structured questionnaires were collected in Zhejiang Province, China. All data were recorded in an electronic system and analyzed.

Results

The prevalence of decayed and filled root caries in 1,076 respondents was 31.9%. Elder age, greater attachment loss, and exposed root surface were associated with higher odds of incidence for decayed/filled roots and decayed roots. In the last 12 months, 27.4% of adults with decayed or filled roots and 23.2% of others utilized oral health services. Carious adults who had a very poor/poor oral health status were 2.905 times likely to report dental visits. People with sound roots who were female (OR = 2.103, P < 0.001), perceived their oral health status as moderate (OR = 1.802, P = 0.015), or poor/very poor (OR = 4.103, P < 0.001) were more likely to visit a dentist in the past 12 months.

Conclusions

Age, attachment loss and root exposure were most significantly associated with the prevalence of root caries. Individuals who recognize their poor or very poor oral health status should feel encouraged to make use of oral health services.

Surgical management of gingival recessions in patients with refractory gingival pemphigus vulgaris: A multidisciplinary challenge

BACKGROUND

Mucogingival surgery for root coverage of gingival recessions (GRs) is usually performed in patients with unremarkable periodontal and systemic health. However, the predictable results of surgical procedures and increasingly high aesthetic expectations of patients necessitate optimal management of GR also in patients with systemic conditions that affect the oral cavity. In patients with pemphigus vulgaris (PV), mucosal fragility and complicated surgical management of inflamed soft tissues are major challenges.

METHODS AND RESULTS

A 36-year-old female patient with PV and deep GR on the mandibular incisors is presented. After initial unresponsiveness to steroids and immunosuppressants, complete clinical remission was achieved through repeated rituximab infusions and topical platelet-rich plasma. After > 1 year of stable clinical remission off therapy the patient successfully underwent surgical procedures for vertically coronally advanced flap with connective tissue graft.

CONCLUSIONS

To the best of our knowledge, no studies have described the surgical management of GR in PV patients. Although controlled studies are required to confirm present results, complete and stable clinical remission is necessary to avoid complications. Collaboration among dermatologists, oral medicine specialists, and periodontologists is essential to determine whether mucogingival surgery for root surface exposure is indicated for PV patients.

KEY POINTS

Why are these cases new information? This is the first report of root coverage in a patient with oral PV What are the keys to the successful management of these cases? The achievement of complete and stable clinical remission from oral PV Multidisciplinary collaboration among dermatologists, oral medicine specialists, and periodontologists What are the primary limitations to success in these cases? The refractoriness of gingival lesions induced by PV Poor mucogingival conditions of inflamed gingival tissues exacerbated by PV.

Evaluation of the Effect of Injectable Platelet-rich Fibrin on Palatal Wound Healing: A Two-arm Randomized Controlled Clinical Trial

AIM

This study aimed to evaluate the effect of injectable platelet-rich fibrin (i-PRF) as a potential catalyst for the acceleration of palatal wound healing after subepithelial connective tissue graft (SCTG) harvesting.

MATERIALS AND METHODS

Referred patients to the Department of Periodontology with the complication of the gingival recession were examined. Thirty participants were chosen for root coverage surgeries with SCTGs, and randomly distributed into two groups; the study group (n = 15) with i-PRF was applied, and the control group (n = 15) without i-PRF. The wound healing index was evaluated on the 7th, 14th, and 30th days of the treatment. Palatal tissue thickness was measured before the treatment and at the 1st, 2nd, and 3rd months after the treatment.

RESULTS

The study group improved significantly the early healing over the control group on days 7 and 14 (p < 0.01), whereas no difference in the first month (p > 0.05) between the groups. Moreover, the study group showed higher tissue thickness mean in the first and second month (p < 0.01), but in the third month, there were no significant differences (p > 0.05) between both groups.

CONCLUSION

The i-PRF has favorable effects on the healing process by enhancing wound healing and increasing the tissue thickness in the palate after SCTG harvesting.

CLINICAL SIGNIFICANCE

For clinicians, it is important to know that we can use biological materials to accelerate healing in general, such as i-PRF. In this study, we used it in the palate, which may accelerate the healing so that we can repeatedly use the same area of the patient's palate for more than one occasion faster.

Effects of fixed retainers on gingival recession - a 10-year retrospective study

OBJECTIVE

The aetiology of gingival recessions is not fully understood, and no evidence has yet emerged of a single predisposing factor that instigates this apical shift of the gingival margin. Nonetheless, both fixed retainers and orthodontic treatment have been cited as potential risk factors. The aim of this study was to assess the effects of orthodontic treatment and orthodontic fixed retainers on gingival recessions.

SUBJECTS AND METHODS

In total, 105 patients at the Department of Orthodontics at the University of Gothenburg who had undergone orthodontic treatment between 1995 - 2003 were included in this study. Intraoral photographs of the anterior segment and study casts acquired at baseline (pre-treatment), post-treatment and at the 10-year follow-up were used as recorded measurements of gingival recession and orthodontic treatment. At the 10-year follow-up, the patients were divided into two groups based on: long-term (10 years) presence of a fixed retainer [orthodontic treatment and retainer (OR) group; N = 76]; and short-term (<5 years) presence of a fixed retainer [orthodontic treatment (O) group; N = 57]. These groups were compared to a control group (C) of untreated subjects (N = 29).

RESULTS

In the anterior segment, gingival recessions were not present at baseline and post-treatment between the two orthodontically treated groups. At the 10-year follow-up, there was no statistically significant difference between the two orthodontically treated groups and the controls.

CONCLUSIONS

Orthodontic treatment per se does not increase the risk for gingival recessions, nor does the use of fixed retainers following orthodontic treatment.

Histological and histomorphometric study of human palatal mucosa: Implications for connective tissue graft harvesting

AIMS

To analyse the histological structure and histomorphometric characteristics of human hard palatal mucosa in order to determine the donor site of choice for connective tissue grafts from a histological point of view.

MATERIALS AND METHODS

Palatal mucosa samples from six cadaver heads were harvested at four sites: incisal, premolar, molar and tuberosity. Histological and immunohistochemical techniques were performed, as was histomorphometric analysis.

RESULTS

In the current study, we found that the density and size of cells were higher in the superficial papillary layer, whereas the thickness of the collagen bundles increased in the reticular layer. Excluding the epithelium, the mean percentage of lamina propria (LP) and submucosa (SM) was 37% and 63%, respectively (p < .001). LP thickness showed similar values in the incisal, premolar and molar regions, and a significantly greater thickness in tuberosity (p < .001). The thickness of SM increased from incisal to premolar and molar, disappearing in the tuberosity (p < .001).

CONCLUSIONS

As dense connective tissue of LP is the tissue of choice for connective tissue grafts, the best donor site from a histological point of view is tuberosity because it is composed only of a thick LP without the presence of a loose submucosal layer.

Accurate gingival recession quantification using 3D digital dental models

Objectives

To develop and validate a method for accurate quantitative assessment of gingival recessions based on superimposition of serial 3D digital models.

Materials and methods

Gingival recessions of mild (0.5–2 mm) and increased (3–7 mm) severity were simulated on stone casts and surface models were created. The outlines of the gingival margins of the mild (A) and severe recessions (B) were compared to the original gingival margins following 3D best fit superimposition through a gold standard technique (GS), which used intact adjacent structures, and the tested method (CC), which used single tooth crowns at the position of recessions, as superimposition reference. The primary outcome was the distance between the most apical point of each corresponding gingival margin along the respective tooth long axis.

Results

For mild recessions, the median difference of the test methods (CC_A) from the reference method (GS_A) was 0.008 mm (IQR: 0.093; range: − 0.143, 0.147). For severe recessions, the median difference of the test method (CC_B) from the reference method (GS_B) was 0.009 mm (IQR: 0.091; range: − 0.170, 0.198). The proposed method (CC) showed very high intra- and inter-operator reproducibility (median: 0.025 and 0.033 mm, respectively).

Conclusions

The suggested method offers highly accurate monitoring of gingival margin changes and diagnosis of gingival recessions using 3D digital dental models. The method is applicable irrespective of changes in tooth position or form, allowing for assessments over any time span.

Clinical relevance

The accurate detection and visualization of gingival margin changes in 3D will enhance diagnosis and patient-doctor communication.

Clinical outcomes of the biologically oriented preparation technique (BOPT) in fixed dental prostheses: A systematic review

STATEMENT OF PROBLEM

The biologically oriented preparation technique is a concept with a vertical tooth preparation, gingitage, an immediate interim restoration preserving the clot, and a specific laboratory technique aiming to adapt the marginal periodontal tissue to a remodeled emergence profile of the crown. However, the published scientific evidence on this subject is limited.

PURPOSE

The purpose of this systematic review was to analyze whether using the biologically oriented preparation technique leads to improved clinical outcomes in terms of probing depth, gingival inflammation index, gingival marginal stability, and fewer mechanical and biological complications.

MATERIAL AND METHODS

Recommendations from the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used in this systematic review. An electronic search of the MEDLINE/PubMed, EMBASE, Science Direct, Wiley Online Library, Cochrane, and ProQuest databases was made for articles published between March 2010 and July 2021 using keywords. Three reviewers selected and analyzed all articles that mentioned the biologically oriented preparation technique and met the inclusion criteria.

RESULTS

A total of 6 articles met the inclusion criteria: 1 prospective randomized clinical study, 1 randomized clinical study, 1 prospective clinical study, and 3 case series. According to these studies, of all the teeth treated with the biologically oriented preparation technique, probing depth (greater than 3 mm) increased in only 2.3%, gingival inflammation was present in 22.8%, gingival recession occurred in 1.7% (decreased gingival stability), and mechanical and biological failures occurred in 4.4% of the teeth.

CONCLUSIONS

Fixed dental prosthesis treatments performed following the concept of the biologically oriented preparation technique did not increase probing depth and showed a moderate rate of gingival inflammation, lower recession rates, and lower mechanical and biological failures at the 5-year follow-up. The biologically oriented preparation technique appears to be a viable alternative technique for obtaining satisfactory and stable clinical results up to 5 years. Long-term randomized clinical trials are recommended to reach more conclusions about this protocol.

Dimensional Influence of Epithelialized Tissue Graft Harvested From Palate on Postoperative Pain: a Systematic Review

Objectives

The aim of the present systematic review was to evaluate the dimensional influence of the epithelialized tissue graft harvested from the palate in the postoperative pain.

Material and Methods

Research was conducted in electronic databases Cochrane Library, Embase, LILACS, PubMed, Scopus, and Web of Science upwards May 15, 2022. Studies that reported the influence of graft dimensions of palatal epithelized harvesting on postoperative pain were eligible. The evaluation was made using the methodological quality assessment by Joanna Briggs Institute Critical Appraisal Checklist for randomized clinical trials and non-randomized studies and the level of evidence according to GRADE.

Results

Four studies were included. The clinical and methodological heterogeneity among studies led to an analysed narrative. The postoperative pain was assessed during the period of 1 to 28 postoperative days. It was determined by using visual analog scale in three studies, while the evaluation was performed indirectly based on analgesics intake in one study. According to three studies, bigger graft sizes were associated with higher postoperative pain. The methodological quality assessment categorized two study as high (one randomized control trial and one non-randomized), and two as moderate (one randomized control trial and one non-randomized). The data was considered moderate.

Conclusions

Based on the moderate certainty level, bigger graft sizes of palatal epithelized harvesting appear to promote more postoperative pain. Understanding the postoperative pain as a response to a graft extension may assist some clinical decisions regarding the surgical periodontal and peri-implant planning.

Hyaluronic Acid as an Adjunct to Coronally Advanced Flap Procedures for Gingival Recessions: A Systematic Review and Meta—Analysis of Randomized Clinical Trials

Previous systematic reviews have reported that coronally advanced flap (CAF) + connective tissue graft (CTG) are the gold standard in root coverage procedures (RCP). Nevertheless, adjunctive treatment with hyaluronic acid (HA) has been proposed to aim at improving clinical outcomes and reducing patient morbidity. The aim of this systematic review and meta-analysis is to compare the use of HA as an adjunctive treatment to CAF procedures in Miller class I and II (recession type 1; RT1) gingival recession (GR) defects treatment with no adjunctive/other treatments. MEDLINE, The Cochrane Central Register of Controlled Trials, Web of Science, Scopus databases and gray literature were searched up to April 2022. The primary outcome variables were mean recession coverage (MRC) and reduction of the recession depth (RecRed). Weighted mean differences and 95% confidence intervals between treatments were estimated using a random-effect mode. From 264 titles identified, 3 RCTs reporting 90 GR defects in 60 patients were included. Overall analysis of MRC and RecRed were 0.27% (p = 0.01) and 0.40 mm (p = 0.45) in favor of CAF + HA compared to CAF alone/CAF + subepithelial connective tissue graft (SCTG), respectively, with a statistically significant difference only for MRC values. Nevertheless, due to the limited number and heterogeneity of the included studies, well-performed RCTs are needed to clarify a potential advantage of HA in RCPs in the future.

Quantitative proteomic analysis of gingival crevicular fluids to identify novel biomarkers of gingival recession in orthodontic patients

OBJECTIVE

To identify gingival recession-related biomarkers in orthodontic patients, we compared the proteome of gingival crevicular fluids (GCF) from healthy gingiva without orthodontic treatment (GH), healthy gingiva undergoing orthodontic treatment (OGH), and recessed gingiva undergoing orthodontic treatment (OGR).

METHODS

GCF samples were obtained from the anterior teeth of 15 volunteers (n = 5/group). Quantitative proteomic analysis was performed using DIA-based liquid chromatography-tandem mass spectrometry (LC-MS/MS). Gene Ontology (GO) terms and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathways were used to annotate differentially expressed proteins (DEPs). Receiver-operating characteristic (ROC) analysis was performed to detect and filter biomarker candidates, while Protein-Protein Interaction (PPI) Networks were utilized to determine the interactions between these DEPs.

RESULTS

A total of 253, 238, and 101 DEPs were found in OGR vs. OGH, OGR vs. GH, and OGH vs. GH groups, respectively. Based on the Venn diagram of three groups, 128 DEPs in OGR vs. OGH group were identified as specific proteins associated with progressive gingival recession (GR) during orthodontic treatment. Molecular function analysis showed that 128 DEPs were enriched in "molecular binding", including antigen binding, RNA binding, double-stranded RNA binding, cadherin binding involved in cell-cell adhesion, vinculin binding, S100 protein binding, and Ral GTPase binding. The majority of these DEPs were also involved in cytoskeletal regulation. In addition, biological process analysis showed an enrichment in translation, while cellular component analysis indicated that 128 DEPs were related to extracellular exosome. Furthermore, Ribosome and Phagosome were the top two terms in KEGG analysis. The results of ROC analysis demonstrated that 26 proteins could be potential biomarker candidates for GR. PPI networks analysis predicted that IQGAP1, ACTN1, TLN1, VASP, FN1, FERMT3, MYO1C, RALA, RPL35, SEC61G, KPNB1, and NPM1 could be involved in the development of GR via cytoskeletal regulation.

CONCLUSIONS

In summary, we identified several GCF proteins associated with GR after orthodontic treatment. These findings could contribute to the prevention of GR in susceptible patients before the initiation of orthodontic treatment.

SIGNIFICANCE

Orthodontic patients with GR often report esthetic defects or root hypersensitivity during orthodontic treatment, especially at the anterior teeth site. GCF, rich in protein, is an easily accessible source of potential biomarkers for the diagnosis of periodontal diseases; however, little is known about the changes in GCF proteome associated with GR in orthodontic patients. In this study we firstly used DIA-based LC-MS/MS to evaluate the proteome and to identify the biomarker candidates for GR in orthodontic patients. These findings will improve our understanding of GR during orthodontic treatment, and could contribute to an earlier diagnosis, or even prevention, of GR in susceptible populations before orthodontic treatment.

The Structure and Function of Next-Generation Gingival Graft Substitutes-A Perspective on Multilayer Electrospun Constructs with Consideration of Vascularization

There is a shortage of suitable tissue-engineered solutions for gingival recession, a soft tissue defect of the oral cavity. Autologous tissue grafts lead to an increase in morbidity due to complications at the donor site. Although material substitutes are available on the market, their development is early, and work to produce more functional material substitutes is underway. The latter materials along with newly conceived tissue-engineered substitutes must maintain volumetric form over time and have advantageous mechanical and biological characteristics facilitating the regeneration of functional gingival tissue. This review conveys a comprehensive and timely perspective to provide insight towards future work in the field, by linking the structure (specifically multilayered systems) and function of electrospun material-based approaches for gingival tissue engineering and regeneration. Electrospun material composites are reviewed alongside existing commercial material substitutes’, looking at current advantages and disadvantages. The importance of implementing physiologically relevant degradation profiles and mechanical properties into the design of material substitutes is presented and discussed. Further, given that the broader tissue engineering field has moved towards the use of pre-seeded scaffolds, a review of promising cell options, for generating tissue-engineered autologous gingival grafts from electrospun scaffolds is presented and their potential utility and limitations are discussed.

Root coverage of a maxillary lateral incisor with gingival recession, gingival stillman's cleft, bony exostosis, and denture stomatitis: a case report with 3-year follow-up

Background

Coronally advanced flap combined with connective tissue graft is considered as the golden standard of root coverage. Although Miller class I recession is considered to get complete root coverage, there are some uncommon conditions in different cases. This case reported a maxillary lateral incisor with a gingival recession, a stillman’s cleft, a bony exostosis and a denture stomatitis.

Case presentation

A 27-year-old female with a gingival recession, a stillman’s cleft and a bony exostosis was treated by coronally advanced flap combined with connective tissue graft technique, and the complete coverage was achieved. Later a denture stomatitis occurred when an acrylic removable partial denture was used, however the gingival margin was not affected. The denture stomatitis disappeared when a new denture with casting palatal plane was produced. In this case of 3-year follow-up, the gingival contour remained stable and the outcome was satisfactory.

Conclusion

Coronally advanced flap combined with connective tissue graft technique is a classic manner to treat gingival recession especially for a long term stability, even when there is a gingival stillman’s cleft, a bony exostosis and a denture stomatitis.

Clinical Outcomes of the Double Lateral Sliding Bridge Flap Technique with Simultaneous Connective Tissue Graft in Sextant V Recessions: Three-Year Follow-Up Study

The presence of isolated or multiple gingival recessions in the mandibular anterior region is a challenge for the clinician, as they may be associated with a shallow vestibule, high frenum insertion and/or little or no attached gingiva. Only limited evidence is available on the use of the double lateral sliding bridge flap technique with connective tissue graft (CTG) technique for treating gingival recessions in the mandibular anterior region. The aim of this study was to describe and evaluate the clinical and esthetic outcomes of the double lateral sliding bridge flap technique with CTG on isolated and multiple gingival recessions at the level of the mandibular incisors. Nine patients required treatment of gingival recessions in the mandibular incisors at the University of Salamanca (Spain) (seven females, two males; mean age: 27.9 ± 6.9) with a total of 14 isolated (42.9%) and multiple (57.1%) Miller class II and III gingival recessions. After a mean follow-up of 36 months, the mean percentage of root coverage was 80.5% for all treated recessions. Statistically significant differences (p < 0.05), were observed for reduction in recession depth, increased width of keratinized tissue and increased gingival thickness, this being dependent on the Miller class. The esthetic outcome was acceptable, with a final mean esthetic score of 7.4 out of 10. The double lateral sliding bridge flap surgical technique with CTG is an effective procedure for the coverage of isolated and multiple gingival recessions in the anterior mandibular region, as it offers satisfactory esthetic results.

The use of medium bristle toothbrushes is associated with the incidence of gingival fissures

OBJECTIVES

The objective of this study was to compare the incidence of gingival fissures (GF) associated with the use of soft and medium bristle toothbrushes over three months.

MATERIAL AND METHODS

A blind randomized crossover clinical trial was conducted with 20 high school students (14 females, 14-24 years old) using both toothbrushes type (soft and medium bristle) during 3 months each. Periodontal examinations and photographs of premolars and molars were recorded on days 0, 30, 60, and 90 of 1st phase. Following a 10-day washout period, the 2nd phase was carried out with the participants changing the assigned brush type. Toothbrushing perception was evaluated at the end of study through a questionnaire. A calibrated and blind examiner analyzed the photographs for GF presence. Differences in the GF incidence between toothbrushes type were analyzed by McNemar test, while factors associated with GF incidence were investigated by Poisson regression.

RESULTS

Sixty-five percent (n = 13) of participants had at least one GF throughout the study, with 40% (n = 8) of them while using medium brushes only (p = 0.039). GF occurrence was significantly associated with medium brushes (IRR, 3.582; 95% CI 1.459-8.795; p = 0.005). 58.8% of participants reported gingival soreness or bleeding with medium brushes.

CONCLUSIONS

Both toothbrushes led to the GF occurrence. Nonetheless, medium bristles toothbrushes determined a 3.58 times greater risk of developing these lesions. Clinical relevance The use of medium bristle brush is associated with greater incidence of gingival fissures. The presence of gingival fissures should be considered by the clinician when evaluating the toothbrushing habits of patients.

An in vivo comparison of wound healing characteristics of two commercial acellular dermal matrices

Objectives

Many acellular dermal matrices (ADMs) are available for use in periodontal surgical procedures. However, few studies exist evaluating their in vivo healing properties. The objectives of this study were to compare the wound healing and remodeling of two ADMs used for gingival augmentation procedures in the rat model.

Materials and methods

This was a nonrandomized controlled split‐mouth study. Envelope flaps were surgically created in the maxillary quadrants of 24 Sprague Dawley rats. Each received either (a) AlloDerm Regenerative Tissue Matrix, or (b) OrACELL. Gingival tissue from one mandibular quadrant served as the untreated control. Six male and six female rats were treated for 7 or 21 days. Biopsies were processed for histologic analysis (H&E, Picro‐sirius red, Verhoeff's solution) or RNA analysis (RT‐PCR) to analyze the expression of type I collagen (Col1a1), fibronectin (Fn‐1) and VEGF‐A (Vegf‐A).

Results

There was a greater density of fibroblasts in OrACELL compared to AlloDerm at both timepoints. There was a greater density of elastin present in AlloDerm compared to OrACELL at 7 days but no differences at 21 days. There were no differences between test groups in the percentage of birefringent collagen or in the expression of Vegf‐A or Fn‐1. At 7 days, there were significantly more fibroblasts for males in the OrACELL group compared to females. At 21 days, there was a significantly greater expression of Col1a1 for males in the OrACELL group compared to females.

Conclusions

Early wound healing and remodeling of OrACELL appeared to occur more rapidly than AlloDerm and was accelerated in male rats. Whether these results have clinical implications for soft tissue grafting procedures in humans remains to be determined.

Platelet-rich fibrin for wound healing of palatal donor sites of free gingival grafts: Systematic review and meta-analysis

Background

Platelet-rich fibrin (PRF) has been referred to as a second-generation platelet concentrate, associated with improvements on the healing of palatal wounds followed by FGG harvesting. The aim of this systematic review and meta-analysis was to assess the complete wound epithelialization and postoperative pain when PRF was used in palatal wounds following free gingival graft (FGG) harvesting.

Material and Methods

PubMed (Medline), EMBASE and Scopus were searched by two independent individuals up to and including March 2020 in order to identify controlled and randomized controlled clinical trials on the use of PRF at palatal donor sites of FGG. The outcomes assessed were epithelialization and postoperative pain. The risk of bias of the included studies was evaluated using Cochrane Collaboration’s domain-based two-part tool. Random effects meta-analyses were conducted with 95% confidence intervals.

Results

The search strategy identified 555 potentially eligible articles, of which 6 randomized controlled clinical trials were included. In the qualitative analysis, most studies (83.3%) reported lower postoperative pain in treatment groups, while all studies accessing epithelialization demonstrated earlier complete wound closure in groups treated with PRF. The discomfort and complete re-epithelialization were more favorable in groups PRF when compared to control groups (P<0.00001).

Conclusions

Within the limits of the present study, it can be concluded that the use of PRF for wound healing of palatal donor sites of FGG may decrease postoperative pain and induce earlier complete wound epithelialization.

Key words:Wound healing, oral surgery procedures, pain, postoperative.

Treatment of Gingival Recession: When and How?

Gingival recession is a common finding in daily clinical practice. Several issues may be associated with the apical shift of the gingival margin such as dentine hypersensitivity, root caries, non-carious cervical lesions (NCCLs), and compromised aesthetics. The first step in an effective management and prevention program is to identify susceptibility factors and modifiable conditions associated with gingival recession. Non-surgical treatment options for gingival recession defects include establishment of optimal plaque control, removal of overhanging subgingival restorations, behaviour change interventions, and use of desensitising agents. In cases where a surgical approach is indicated, coronally advanced flap and tunnelling procedures combined with a connective tissue graft are considered the most predictable treatment options for single and multiple recession defects. If there is a contraindication for harvesting a connective tissue graft from the palate or the patient wants to avoid a donor site surgery, adjunctive use of acellular dermal matrices, collagen matrices, and/or enamel matrix derivatives can be a valuable treatment alternative. For gingival recession defects associated with NCCLs a combined restorative-surgical approach can provide favourable clinical outcomes. If a patient refuses a surgical intervention or there are other contraindications for an invasive approach, gingival conditions should be maintained with preventive measures. This paper gives a concise review on when and how to treat gingival recession defects.

Surgical-Periodontal aspects in orthodontic traction of palatally displaced canines: a meta-analysis

The aim was to determine whether there is a difference in the periodontal aspect (gingival recession, probing pocket depth) of the palatally displaced canine (PDC) compared to the contralateral canine. Also, from a surgical perspective, sought to determine whether there is a difference (surgical duration, postoperative pain) between the surgical techniques. The word combinations were adapted for each electronic database: PubMed, LILACS, Scopus, Web of Science, Cochrane Library and gray literature. Studies that met the following criteria were considered eligible: (P) Patients who received orthodontic-surgical treatment for correction of PDC; (I) Performing orthodontic-surgical treatment for traction of the PDC; (C) Comparison of the tractioned canine with its contralateral or between the two techniques; (O) Gingival recession, probing pocket depth, postoperative complications and surgical duration; (S) Randomized and nonrandomized clinical studies or observational studies. The overall prevalence of gingival recession was estimated to be 10.53% [95% CI, 3.87% - 25.59%; I² = 88%]. No statistically significant difference (p > 0.05) was found between the means of the variables gingival recession, probing pocket depth and surgical duration. The evidence suggests that traction of palatally displaced canines can be considered a reliable and acceptable procedure.

Use of digital periodontal data to compare periodontal treatment outcomes in a practice-based research network (PBRN): a proof of concept

Background

Scientific studies in dentistry are mainly conducted at universities. However, most patients are treated in dental practices, which differ in many ways from treatment at the university. Through the establishment of practice-based research networks, however, it is also possible to examine studies in a real-world setting in dental practices. For this reason the aim of this non-interventional, observational study was to develop and evaluate a digital procedure to access, extract and analyse recorded clinical data in practices to assess periodontal treatment outcomes.

Methods

Participating periodontists were former or active postgraduate students of a master’s course in periodontics in Freiburg who routinely used a digital periodontal diagnostic program. All available stored periodontal patient charts were extracted, anonymized and digitally sent to the study centre.

Results

In this study, data were collected from 6301 patients from 9 different practices. Information such as probing depth (PD), bleeding on probing (BOP), mobility, furcation and gingival attachment for 153,163 teeth at first visit were successfully transferred to the study centre. During the average observational period of 9.77 years, only 2.8% of all teeth were lost. The number of visits was significantly negatively correlated with BOP (p < 0.0001), and the number of BOP-positive sites was significantly correlated with deeper PDs (p < 0.001).

Conclusion

The presented procedure was able to gather a large amount of practice-based periodontal data, and thus this study may support practice-based research networks. The data indicate that systematic and supportive periodontal therapy is successful on a practice-based level.

Trial registration The study was internationally registered on 4 January 2017 in the German Clinical Trials Register (DRKS 00011448). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00011448

Phenytoin sodium-ameliorated gingival fibroblast aging is associated with autophagy

BACKGROUND AND OBJECTIVE

Human gingival fibrolasts aging is an important cause of periodontal disease. Phenytoin sodium (phenytoin) has a side effect of gingival hyperplasia and an effect on the autophagy progress. This study investigated whether the effect of phenytoin on aging gingival fibroblast is related to the autophagy pathway.

MATERIAL AND METHODS

The aging model of gingival fibroblast cell line HGF-1 was induced by hydrogen peroxide (H₂ O₂ ), and the treatment of phenytoin and 3-methyladenine (3-MA) was performed simultaneously. Cell viability, cell cycle, and intracellular calcium ion were measured by flow cytometry. Changes in expression of basic fibroblast growth factor (bFGF), P16^INK4A , P21^cip1 , and bFGF, P16^INK4A , P21^cip1 , LC3II, p62, and Beclin were tested by using reverse transcription polymerase chain reaction, western blot, and immunofluorescence staining.

RESULTS

The results showed that aging HGF-1 proliferation was inhibited by H₂ O₂ , gene, protein expression of bFGF, P16^INK4A , and P21^cip1 were decreased, autophagy-related proteins LC3II, p62, and Becline were decreased, and the proportion of G0/G1 phase and intracellular calcium ion of cell cycle was increased. Phenytoin treatment could recovery above changes, but the effect of phenytoin could be blocked by 3-MA.

CONCLUSION

We propose that phenytoin alleviates the aging of gingival fibroblasts induced by H₂ O₂ . This condition is related to the enhancement of autophagy pathway.

Medical reliability of a video-sharing website: The gingival recession model

OBJECTIVES

To evaluate the quality of the scientific/clinical information in dentistry delivered by videos hosted by a popular video-sharing website.

METHODS

The gingival recession condition was used as a model and YouTube™ as the video hosting service. A systematic observation of videos containing information on gingival recession was conducted. Videos were analysed to evaluate (i) the scientific reliability and quality of the information using Global Quality Scale (GQS) and DISCREN criteria; and (ii) the understandability of this information using a tailor-made custom comprehensiveness index (CI).

RESULTS

One hundred and eighty videos were identified. Videos dealing with surgical procedures were not included in the present review. After selection, 41 videos were analysed. The mean GQS was 2.34 on a 0-5 scale, and 25 (61%) videos showed clear aims according to DISCREN criteria. Misleading content was observed in eight videos (19.5%). The scientific sources of information were unclear in 26 (63.4%) videos. All videos failed to give additional references for supplemental information. Only three videos (7%) provided basic information on aetiology, clinical presentations and management of gingival recession. Based on 0-2 CI scores, three, nine and 29 videos had a score of 2, 1 and 0, respectively.

CONCLUSION

The present model indicates that social media websites aiming to provide health information should be carefully accounted, especially when dealing with dentistry. It also suggests professional involvement to improve the quality of the delivered information.

Gingival recession in mandibular incisors and symphysis morphology-a retrospective cohort study

Objective

To evaluate if the morphology of the mandibular symphysis is associated with the development of gingival recession.

Materials and methods

A cohort of 177 patients was followed longitudinally for up to 5 years post-treatment. Based on the width of the symphysis, participants were divided into three groups: narrow (n = 57); average (n = 63), and wide symphysis (n = 57). Morphology of the symphysis and inclination of incisors were measured on lateral cephalometric radiographs before treatment (Ts), at the end of treatment (T0) and 5 years after treatment (T5). Gingival recession and the change of clinical crown heights in mandibular incisors were measured on plaster models made at TS, T0, and T5.

Results

From TS to T5 the change in inclination was comparable in the narrow, average, and wide groups. At T5, gingival labial recession was present in 19.3 per cent of patients with narrow symphysis, 20.6 per cent with average symphysis, and 14 per cent of patients with wide symphysis. The difference was not significant. The mean change of clinical crown height was <1 mm (TS - T5). The regression model showed some evidence that incisor inclination at Ts might have been associated with the change of mean clinical crown height (-2.51, 95% CI: -4.6 to -0.4, P = 0.02). The logistic regression model demonstrated that H1 (Height 1) might be associated with the development of gingival recession (OR = 0.75, 95% CI: 0.58 to 0.96, P = 0.03).

Conclusion

Within the limitations of this study, there is no evidence that the overall morphology of the mandibular symphysis is associated with gingival recession development.

Topical application of phenytoin or nifedipine-loaded PLGA microspheres promotes periodontal regeneration in vivo

OBJECTIVES

Gingival recession and alveolar bone loss are common manifestations of periodontitis. Periodontal regeneration is the ideal strategy for rehabilitating periodontal tissue defects and preventing tooth loss. The present study examined whether localized, topical application of gingival overgrowth-inducing drugs, phenytoin, nifedipine or cyclosporine, induces periodontal regeneration.

METHODS

Polylactic-co-glycolic acid (PLGA) was used as the carrier for preparation of phenytoin, nifedipine or cyclosporine-loaded PLGA microspheres, using an oil-in-water emulsification technique. The drug-loaded microspheres were delivered to periodontal defects created on alveolar ridges mesial to the first maxillary molars of Sprague-Dawley rats. After eight weeks, the operation area in each rat, including the maxillary molars and periodontal tissues, was harvested and evaluated by micro-computed tomography, histochemical and immunohistochemical analyses.

RESULTS

Physical parameters representative of periodontal regeneration, including the length of new alveolar bone (p < 0.01) and the area of new alveolar bone (p < 0.01) were significantly improved in the phenytoin group. Compared to other groups, the phenytoin group demonstrated increased expression of COL-1, VEGF-A, osteoblast and osteoclast markers (BMP-2, TGF-β1, OCN and TRAP staining), as well as decreased expression of MMP-8.

CONCLUSIONS

Results of the present study provided new evidence that localized, controlled release of phenytoin confers therapeutic benefits toward gingival recession and alveolar bone loss. Phenytoin appears to be a promising drug that promotes periodontal regeneration.

Prospective Clinical Study of Zirconia Full-coverage Restorations on Teeth Prepared With Biologically Oriented Preparation Technique on Gingival Health: Results After Two-year Follow-up

Objectives:

To evaluate the clinical behavior of one-piece complete-coverage crowns and fixed partial dentures (FPDs) on teeth with vertical preparation without finish line biologically oriented preparation technique (BOPT).

Methods and Materials:

This prospective study included 52 patients requiring treatment with restorations in the esthetic region: 74 crowns and 27 FPDs. The sample included a total of 149 teeth that were prepared vertically without finish line. The sample was divided into two groups: one-piece crowns and FPDs, all with zirconia cores, feldspathic ceramic veneer, and a 0.5-mm prosthetic finish line of zirconia. All procedures were carried out at the University of Valencia from 2013 to 2014. The following parameters were evaluated over a two-year follow-up: oral hygiene, periodontal state, gingival thickening, gingival margin stability, the presence of complications, and restoration survival rate. Patient satisfaction with treatment was assessed by means of a visual analogue scale (VAS).

Results:

Two years after treatment, 80.5% of treated teeth remained free of gingival inflammation and bleeding. Mean gingival thickening was 0.41 ± 0.28 mm for one-piece crowns and 0.38 ± 0.36 mm for FPDs. Gingival margin stability was 100%, but 2% of the sample presented biological complications. The VAS patient satisfaction scores were eight out of a maximum score of 10.

Conclusions:

Two years after treatment, vertical preparation without finish line produces gingival thickening, margin stability, and optimal esthetics. Neither crowns nor FPDs presented any mechanical complications.

The Periodontium as a Potential Cause of Orofacial Pain: A Comprehensive Review

Introduction:

Orofacial pain of periodontal origin has a wide range of causes, and its high prevalence and negative effect on patients' quality of life make intervention mandatory. This review provides a periodontological overview of the field of orofacial pain, focusing on the entities which involve the periodontal tissues and may be the cause of this pain or discomfort.

Methods:

The study comprised a literature search of these pathologies conducted in the MEDLINE/PubMed Database. Acute infectious entities such as gingival and periodontal abscesses are emergencies that require a rapid response. Periodontitis associated with endodontic processes, necrotizing periodontal disorders, desquamative gingivitis, gingival recession, and mucogingival herpetic lesions, cause mild to severe pain due to tissue destruction and loss. Other lesions that lead to periodontal discomfort include gingival enlargement and periodontal ligament strains associated with occlusal trauma, parafunctional habit and the impaction of food or foreign bodies.

Conclusion:

A range of therapeutic, pharmacological and surgical alternatives are available for the management of these injuries. However, the wide variety of causes of orofacial pain or periodontal discomfort may confuse the clinician during diagnosis and may lead to the wrong choice of treatment.

Periodontitis: facts, fallacies and the future

This volume of Periodontology 2000 represents the 25th anniversary of the Journal, and uses the occasion to assess important advancements in periodontology over the past quarter-century as well as the hurdles that remain. Periodontitis is defined by pathologic loss of the periodontal ligament and alveolar bone. The disease involves complex dynamic interactions among active herpesviruses, specific bacterial pathogens and destructive immune responses. Periodontal diagnostics is currently based on clinical rather than etiologic criteria, and provides limited therapeutic guidance. Periodontal causative treatment consists of scaling, antiseptic rinses and occasionally systemic antibiotics, and surgical intervention has been de-emphasized, except perhaps for the most advanced types of periodontitis. Plastic surgical therapy includes soft-tissue grafting to cover exposed root surfaces and bone grafting to provide support for implants. Dental implants are used to replace severely diseased or missing teeth, but implant overuse is of concern. The utility of laser treatment for periodontitis remains unresolved. Host modulation and risk-factor modification therapies may benefit select patient groups. Patient self-care is a critical part of periodontal health care, and twice-weekly oral rinsing with 0.10-0.25% sodium hypochlorite constitutes a valuable adjunct to conventional anti-plaque and anti-gingivitis treatments. A link between periodontal herpesviruses and systemic diseases is a strong biological plausibility. In summary, research during the past 25 years has significantly changed our concepts of periodontitis pathobiology and has produced more-effective and less-costly therapeutic options.

Low-level laser therapy as an adjunct to connective tissue graft procedure in the treatment of gingival recession defects: A systematic review and meta-analysis

OBJECTIVE

The aim of this study was to systematically evaluate the effectiveness of low level laser therapy (LLLT) as an adjunct to connective tissue graft (CTG) procedure for the treatment of gingival recession (GR).

MATERIALS AND METHODS

The addressed PICO question was; "In patients with Miller Class I or II recession defects (Population), what is the effect of LLLT as adjunct to CTG (Intervention) in comparison to CTG alone (Comparison) on gingival recession depth (Outcome)" Electronic databases were searched up to December 2017. Primary outcomes included gingival recession depth (GRD), whereas secondary outcomes were width of keratinized tissue (WKT) and relative clinical attachment level gain (RCAL). The weighted mean differences (WMD) of outcomes and 95% confidence intervals (CI) for each variable were calculated using random effect model.

RESULTS

Four randomized clinical studies were included. Two studies showed significantly greater improvements with LLLT whereas, 2 studies showed comparable outcomes between LLLT and CTG group. Considering the effects of adjunctive LLLT as compared to CTG, a high degree of heterogeneity for GRD (Q value = 9.40, P = .02, I² =68.11%) and WKT ((Q value = 16.04, P = .001, I² =81.31%) was noticed among both the groups. Meta-analysis showed a statistically significant GRD (WMD= -0.61, 95% CI= -1.23 to 0.004, P = .05) for LLLT + CTG treatment versus CTG alone only.

CONCLUSIONS

LLLT improves clinical and patient-centered outcomes of CTG procedures for the treatment of GR remains debatable. However, due to the small number of included studies and high heterogeneity in the laser parameters, precautions must be exercised when interpreting the results of the present systematic review.

CLINICAL SIGNIFICANCE

Gingival recessions in dentistry are of major esthetic concern. Minimal gingival recessions can be treated by flap operations, but the predictability and stability of the outcomes is debatable. In the present review, low level laser therapy (LLLT) adjunct to connective tissue graft (CTG) depicted a significant improvement in the predictability and stability of root coverage outcomes compared with CTG alone.

Fifteen-Year Follow-Up of a Case of Surgical Retreatment of a Single Gingival Recession

Purpose

The aim of the present case report was to describe the retreatment of the single gingival recession in aesthetic area, in the presence of scar formation and consequent impairment of aesthetic appearance.

Methods

A young patient with one single recession of 4 mm of 2.1 was treated with coronally advanced flap and subepithelial connective tissue graft, through a microsurgical approach that aimed at the removal of the scarred fibrous tissue. The intervention was performed using a surgical microscope as a magnification device.

Results

Fifteen years after the surgical treatment, a substantial stable resolution of the gingival recession could be observed. Moreover, a further improvement of the aesthetic appearance could be observed.

Conclusions

This case report suggests that periodontal microsurgery could be an effective approach for the retreatment of gingival recessions and, in long-term evaluation, to reduce the aesthetic problem due to the presence of scar formation. Further studies with a larger sample size are needed to better evaluate its efficacy.

Blood flow changes using a 3D xenogeneic collagen matrix or a subepithelial connective tissue graft for root coverage procedures: a pilot study

BACKGROUND

The study investigated the early healing process following the treatment of single Miller class I and II recessions with a 3D xenogeneic collagen matrix (CMX) or connective tissue graft (CTG).

METHODS

This pilot investigation was designed as a single-center randomized controlled parallel trial. A total of eight subjects (four per group) were treated with either CMX or CTG in the anterior maxilla. Vascular flow changes were assessed by laser Doppler flowmetry (LDF) before and after surgery and at days 1, 2, 3, 7, 14, and 30 while clinical evaluations took place at baseline and at days 60 and 180. Pain intensity perception was evaluated by the short-form McGill pain questionnaire (SF-MPQ), at days 1 and 14.

RESULTS

The vascular flow fluctuated similarly in both groups pre- and post-operatively, but the CTG exhibited a more homogeneous pattern as opposed to CMX that showed a second phase of increased blood flow at 14 days. Clinically, the CTG led to greater change in mean root coverage and keratinized tissue gain but CMX was associated with lower early pain intensity scores.

CONCLUSIONS

Within the limits of the study, the vascular flow alterations during the early healing of both graft types followed a similar pattern. The CMX was associated with a second peak of increased blood flow.

CLINICAL RELEVANCE

The vascular flow changes after the application of CMX for single tooth recession root coverage did not show major differences from those observed after the use of a CTG. A trend for better clinical performance in terms of root coverage and keratinized tissue gain was noted for the CTG, but the initial patient morbidity was less for CMX.

Continuous eruption of maxillary teeth and changes in clinical crown length: A 10-year longitudinal study in adult women

BACKGROUND

Continuous physiologic eruption of teeth may become a main aesthetic issue for implants inserted in the maxillary anterior region.

PURPOSE

To study maxillary tooth vertical changes during a 10 years period by 3-dimensional superimposition of digital dental casts.

MATERIAL AND METHODS

Alginate impressions were taken at both baseline and at the 10-year follow-up in a sample of 24 adult Swedish women (average age of 48 years at T0). The upper arch plaster casts were digitized with a 3-dimensional scanner and then superimposed on the palate and the palatal rugae. Occlusal and gingival anatomic structures were digitized for each upper tooth from first molar to first molar. The vertical changes of these structures gave an indication of tooth extrusion and apical or coronal displacement of the gingival margin.

RESULTS

A trend was found for eruption in the anterior region (+0.3 mm on average) while a slight extrusion if not any was found in the first molars and premolars area. Vertical displacement of the gingival margin showed also a positive trend from first molars to incisors. Negative average values, corresponding clinically to gingival recession, were found on first molars (-0.36 mm) and premolars (-0.15 mm), while no displacement was detected in the anteriors. Clinical crown lengths increased in all teeth and it is mainly due to gingival recession for first molars and premolars, while for the incisors the eruption is coupled to a slight equivalent gingival coronal migration.

CONCLUSIONS

During a 10-year period, continuous eruption takes place in female adult subjects, especially in the upper incisors area while gingival recession occurred in first molars and premolars area leading to crown length elongation. Implant placement in the anterior area of the maxilla may have an aesthetic impact even in mature adults due to the continuous eruption of the adjacent teeth.

Does Evidence Support a Combined Restorative Surgical Approach for the Treatment of Gingival Recessions Associated With Noncarious Cervical Lesions?

OBJECTIVES

Gingival recessions are frequently associated with noncarious cervical lesions. Combined restorative surgical approaches have been suggested for the management of these combined defects. The aim of this review was to analyze the current evidence on the effectiveness of these combined restorative surgical approaches.

METHODS

A systematic review of randomized controlled studies published from January 2006 to June 2016 was performed.

RESULTS

Ten articles comparing combined restorative surgical approaches to surgery alone were included. Both the procedures showed similar outcomes in term of root coverage but the combined restorative surgical approach achieved better result in the reduction of dentin hypersensitivity. In combined restorative surgical treatments, resin-modified glass ionomers showed better antimicrobial properties but poorer esthetic outcome than resin composites.

CONCLUSION

Data to support or refute definitely the interest of combined approaches for the treatment of gingival recessions associated with noncarious cervical lesions are limited.

Substrate roughness induces the development of defective E-cadherin junctions in human gingival keratinocytes

Purpose

The entry of bacteria or harmful substances through the epithelial seal of human gingival keratinocytes (HGKs) in the junctional epithelium (JE) is blocked by specialized intercellular junctions such as E-cadherin junctions (ECJs). However, the influence of roughened substrates, which may occur due to apical migration of the JE, root planing, or peri-implantitis, on the development of the ECJs of HGKs remains largely unknown.

Methods

HGKs were cultured on substrates with varying levels of roughness, which were prepared by rubbing hydrophobic polystyrene dishes with silicon carbide papers. The activity of c-Jun N-terminal kinase (JNK) was inhibited with SP600125 or by transfection with JNK short hairpin RNA. The development of intercellular junctions was analyzed using scanning electron microscopy or confocal laser scanning microscopy after immunohistochemical staining of the cells for E-cadherin. The expression level of phospho-JNK was assessed by immunoblotting.

Results

HGKs developed tight intercellular junctions devoid of wide intercellular gaps on smooth substrates and on rough substrates with low-nanometer dimensions (average roughness [Ra]=121.3±13.4 nm), although the ECJs of HGKs on rough substrates with low-nanometer dimensions developed later than those of HGKs on smooth substrates. In contrast, HGKs developed short intercellular junctions with wide intercellular gaps on rough substrates with mid- or high-nanometer dimensions (Ra=505.3±115.3 nm, 867.0±168.6 nm). Notably, the stability of the ECJs was low on the rough substrates, as demonstrated by the rapid destruction of the cell junction following calcium depletion. Inhibition of JNK activity promoted ECJ development in HGKs. JNK was closely associated with cortical actin in the regulation of ECJs in HGKs.

Conclusions

These results indicate that on rough substrates with nanometer dimensions, the ECJs of HGKs develop slowly or defectively, and that this effect can be reversed by inhibiting JNK.

Minimally invasive periodontal therapy for general practitioners

There remains a high prevalence of mild-to-moderate forms of periodontal diseases in both developed and developing countries. Although many periodontal specialty practices currently place strong emphasis on implant surgery, periodontal plastic surgery and esthetics, general dentists and hygienists have often assumed more responsibility than periodontal specialty practices for the diagnosis, treatment, assessment and maintenance, and possible referral, of their patients. To address these current trends and challenges, this volume of Periodontology 2000 presents a series of topics on the basic biological principles of periodontal disease, as well as on approaches to diagnosis, treatment planning and treatment, in what is called 'conservative' or 'noninvasive' periodontal therapy. These topics include risk assessment of the periodontal condition; reduction, elimination and/or control of etiologies and risk factors, including mechanical, antimicrobial and host-modulation approaches; considerations for evaluation of clinical outcomes based on treatment approaches; and selected topics in laser therapy, halitosis and gingival recession.